For Release: October 31, 2003
Contact: ACOG Office of Communications
New ACOG Opinion Addresses Elective Cesarean Controversy
Washington, DC -- A new committee opinion from The American College of Obstetricians and Gynecologists (ACOG) addresses the controversy of elective cesarean delivery, using it as an example of how doctors can ethically help patients make decisions about surgical treatment when there is a lack of firm evidence for or against such surgery.
In "Surgery and Patient Choice: The Ethics of Decision Making," ACOG notes that while the right of patients to refuse unwanted surgery is well known, less clear is the right of patients to have a surgical procedure when the scientific evidence supporting it is incomplete, of poor quality, or totally lacking -- a frequent scenario in medicine.
Examples might include a 30-year-old healthy woman without a family history of ovarian cancer wanting to have her ovaries removed to prevent such a cancer; a woman with fibroids wanting an experimental surgical treatment whose long-term effects are still unknown; or an 18-year-old woman without children wanting a sterilization procedure.
Where medical evidence is still limited, ACOG says there is no one answer on the right ethical response by a physician considering a patient request for surgery. Thus the decision on whether to perform an elective cesarean delivery (also known as "patient choice cesarean" or "cesarean on demand") will come down to a number of ethical factors including the patient's concerns and the physician's understanding of the procedure's risks and benefits.
In the case of an elective cesarean delivery, if the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than does vaginal birth, then he or she is ethically justified in performing a cesarean delivery. Similarly, if the physician believes that performing a cesarean would be detrimental to the overall health and welfare of the woman and her fetus, he or she is ethically obliged to refrain from performing the surgery. In this case, a referral to another health care provider would be appropriate if physician and patient cannot agree on a method of delivery.
ACOG's Ethics Committee, which produced the opinion, says that the burden of proof should fall on those who advocate for a change in policy in support of elective cesarean delivery (which replaces a natural process -- vaginal delivery -- with a major surgical procedure). Therefore, physicians are under no obligation to initiate discussions about a procedure such as elective cesarean that is unproven scientifically or that the individual physician may not consider medically acceptable.
An increasing number of women are requesting elective cesarean instead of vaginal delivery in the belief that the surgery will prevent future pelvic support or sexual dysfunction problems, or for other reasons. A number of physicians believe that such surgery should not be selected over a natural process without immediate and compelling medical need.
ACOG cautions that "both sides to this debate" must recognize that evidence to support the benefit of elective cesarean is still incomplete and that there are not yet extensive morbidity and mortality data to compare elective cesarean delivery with vaginal birth in healthy women. With better data, there may be a shift in clinical practice.
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The American College of Obstetricians and Gynecologists is the national medical organization representing over 45,000 members who provide health care for women.